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Progression Strategy
Discussion
August 5, 2016
Current All-Payer Model
Original All-Payer Model Application:
Maryland’s Strategy
Aim: Over a 5 year period, achieve the goals of better care, better health and
lower costs.
3
Recap: Stakeholder-Driven Strategy for Maryland
Aligning common interests and transforming the delivery system are key to
sustainability and to meeting Maryland’s goals
Focus Areas
Description
Care Delivery
• Improve care delivery and care coordination across episodes of care
• Tailor care delivery to persons’ needs with care management interventions,
especially for patients with high needs and chronic conditions
• Support enhancement of primary and chronic care models
• Promote consumer engagement and outreach
Health
Information
Exchange and
Tools
• Connect providers (physicians, long-term care, etc.) in addition to hospitals
• Develop shared tools (e.g. common care overviews)
• Bring additional electronic health information to the point of care
Provider
Alignment
• Build on existing models (e.g. hospital GBR model, ACOs, medical homes,
etc.)
• Leverage opportunities for payment reform, common outcomes measures
and value-based approaches across models and across payers to help drive
system transformation
4
Recap: Strategy for Implementing the All-Payer Model
Year 1 Focus
Initiate hospital payment
changes to support delivery
system changes
Focus on person-centered
policies to reduce potentially
avoidable utilization that
result from care
improvements
Engage stakeholders
Build regulatory
infrastructure
Years 2-3 Focus (Now)
Work on clinical
improvement, care
coordination, integration
planning, and infrastructure
development
Partner across hospitals,
physicians, other providers,
post-acute and long-term
care, and communities to plan
and implement changes to
care delivery
Alignment planning and
development
5
Years 4-5 Focus
Implement changes, and
improve care coordination
and chronic care
Focus on alignment models
Engage patients, families, and
communities
Focus on payment model
progression, total cost of care
and extending the model
Progression of the All-Payer
Model
Maryland All-Payer Model Driver Diagram
With Updates for the Model Progression
Aim
Over a 10 year period, achieve the
goals of better care, better health,
and lower costs driven by a personcentered approach to health care
that optimizes outcomes and value
for all Maryland residents.
1. Reduce total all payer per capita
hospital expenditures
• Decrease hospitalizations
• Decrease ED use
• Match patients with appropriate
care setting
2. Improve quality of health
• Decrease admissions
• Decrease hospital acquired
conditions
3. Improve population health measures
4. Limit the growth in Medicare total
cost of care, including the Medicaid
costs for dually eligible beneficiaries
• Improve efficiency and quality of
episodes of care
5. Consider all patients, all payer
principles and their application in the
development of models, measures, and
infrastructure
Primary Drivers
Coordinate interdisciplinary
care across settings and
providers
Improve clinical processes
Improve patient and caregiver
engagement and education
Improve access to care
Improve communication across
providers, patients, and
settings
Enhance and align outcome
measures and financial
incentives for all types of
providers
Data driven continuous process
improvement
Focus on prevention and health
Secondary Drivers
• “Whole person” care management and care planning
• Effective transitions across settings and as care needs
change
• Data-driven, population care management
• Effective management of chronic and co-morbid
conditions
• Effective medication management
• High quality, efficient episodes
• Patient self-management
• Informed and shared decision making
• Patient engagement
• Integration with Patient Centered Medical Homes
• Care coordination
• Enhanced, community-based behavioral health
• Sharing information at the point of care
• Optimal HIT use and information sharing
• Effective patient and caregiver communication
•
•
•
•
Accountability for cost and quality
Standardized clinical measures
Shared savings
All-payer innovations
• Peer-based, rapid cycle learning
• Enhanced data capture and analysis
• Population health plans
• Patient education
Maryland’s Updated Strategy

Updated Aim: Over a 10 year period, achieve the goals of better care,
better health, and lower costs driven by a person-centered approach to
health care that optimizes outcomes and value for all Maryland residents.
 1. Reduce total all payer per capita hospital expenditures




8

Decrease hospitalizations

Decrease ED use

Match patients with appropriate care setting
2. Improve quality and efficiency of health care

Decrease admissions

Decrease health care acquired conditions

Improve efficiency and quality of episodes of care
3. Improve population health measures
4. Limit the growth in Medicare total cost of care, including the Medicaid
costs for dually eligible beneficiaries
5. Consider all patients, all payer principles and their application in the
development of models, measures, and infrastructure
Progression Plan: Scope
Approximate CY 2015 Figures (for 6 million Marylanders)
All Payer Hospital Revenues
(Maryland Residents in Maryland hospitals)
$14.8 billion
Medicare Non-Hospital Spend
(Maryland Beneficiaries anywhere)
$3.9 billion
Medicare Hospital Spend Non-Regulated
$0.5 billion
Medicaid Costs for Dual Eligible Patients
$2.0 billion
Total Costs to be Addressed in the Strategic Plan
$21.2 billion
Notes:
Regulated hospital revenues incorporate ~$4.8 billion of Medicare spend.
Medicare spend includes only payments by Medicare.
Medicare non-regulated hospital spend is primarily out-of-state hospital spend. Also includes in-state
specialty hospital spend.
Medicaid figures are estimated and may be updates.
1)
2)
3)
4)
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Test Several Concepts Along with Hospital Model to
Take on Responsibility for TCOC and Outcomes
Need to address all Medicare beneficiaries
ACOs
200,000
beneficiaries?
10
Medical Home
or other
Aligned Models
Duals Model
(TBD)
Geographic
(Hospital + NonHospital) Model
200,000
beneficiaries?
91,000
beneficiaries?
400,000
beneficiaries?
Tackling TCOC

How to start addressing TCOC


11
Start receiving TCOC data and data to support care coordination and
chronic care improvement and more efficient high quality episodes (the
Amendment)
Learn how to utilize data and make delivery system changes that act on
the most significant opportunities for care improvement and controlling
costs, including:
 A medical home approach that cuts across payers and models
 Patients with high needs and chronic conditions
 Population health
 Episode costs and outcomes (including post-acute)
All-Payer Model: Progression
Strategy Blueprint
Strategic Considerations:

Allow all system components and consumers, including physicians, longterm care, behavioral health, and others, to participate in care delivery and
payment transformation initiatives

Align hospital and provider performance measures and incentives

Support providers/practitioners in practice transformation (e.g. streamlining
administrative requirements)

Assist providers with qualifying for additional funding under MACRA
(financial incentives under MIPS and Advanced APM bonuses)

Leverage current strengths, works in-progress, and available funding from
the federal government

Build in the flexibility to:


Improve models over time
Allow for adaptation in a dynamic health care system
Please refer to Progression Strategy Blueprint document for Design Principles
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Starting to Address the Strategic Considerations:
Care Redesign Amendment

In response to stakeholder input, the State is proposing a Care Redesign
Amendment to the All-Payer Model, which will allow needed approvals (Safe
harbors, Stark, etc.) and data for care redesign and alignment

Opportunity to incorporate physicians and other providers in focus on All Payer
hospital costs and Medicare TCOC

Have a “living” program that allows for annual adjustments as we learn how to deploy
interventions, test new models (e.g. considering episodes) and focus on TCOC

Focus on addressing MACRA coverage for the All Payer Model
Complex & Chronic Care
Improvement Program
Hospital Care Improvement
Program
Long-term / Post-acute Models
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Align community
providers
Align providers
practicing at hospitals
Align other nonhospital providers

Tools:

Shared care coordination resources

Detailed Medicare data for care
coordination

Medicare TCOC data

Shared savings from hospitals

Possible MACRA Advanced APM
status
Progression Strategy Blueprint: Areas for
Consideration

Consider transformation in the following strategy areas:
Payment and Delivery Approaches
1.
Primary/Complex Care
1.
1.
2.
3.
4.
Episodes
2.
1.
2.
Amendment—Hospital Care Improvement
Post acute
TCOC Focus
2.
1.
2.
3.

Amendment--Complex and Chronic Care
Comprehesive Primary Care
Behavioral health
Long term care
Geographic Population Model (including leveraging Amendment) transitioning to upside/downside
incentive payments and or risk
Dual Eligibles ACO/PCMH transitioning to upside/downside risk
Continuing/Increasing ACO/PCMH approaches transitioning to upside/downside risk
Questions for consideration:



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Are these elements the right ones?
What is the timeline? How should the strategies and models be prioritized? What is the
best phased approach?
How should we go about developing the plan and the models?
Envisioning Core Strategic Elements

Primary Care/Complex and Chronic Care

Create a person-centered locus of care with supporting interdisciplinary
care teams across all care settings, data-driven care coordination, and
financial incentives that move towards greater accountability.

Behavioral Health


Long-term Care

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Improve access to community-based, behavioral health services, promote clinical
integration between primary care and behavioral health, and develop value-based
payment mechanisms
Create value-based payment and care delivery mechanisms that improve care
coordination and delivery of long-term care and home and community-based
services
Envisioning Core Strategic Elements (cont.)

Post-acute Care


Geographic Population Model


Create alignment between hospitals and post-acute providers and
facilities that optimizes transitions and resource use across care settings
(e.g. acute, post-acute, long-term care, home, etc.)
Promote All-Payer Model progression through an accountability model
that creates local responsibility for patient health outcomes and total
cost of care in an actionable geographic area, first focusing on Medicare
Dual Eligibles

17
Create payment and care delivery mechanisms that improve care
coordination and access to care for Dual Eligible beneficiaries, and
incorporate payer accountability for Dual Eligible total cost of care (e.g.
including medical and custodial care)
Potential Timeline
MACRA APM status
provides bonus for
participating
providers. Bonus
adjusted based on
model outcomes
MACRA
Begin to implement
MACRA-eligible
models
2017
2018
• Care Redesign
Amendment
– Complex and
Chronic Care
– Hospital Care
Improvement
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• Primary Care
model*
• Geographic
Population
model*
• Shared savings
component
added to Care
Redesign
Amendment
programs*
2019
• Geographic
Model*, ACOs*,
and PCMH*
models begin to
take on more
responsibility
• Dual Eligible
model*
2020
TBD
• Post-acute
• Behavioral
health
• Long term
care
Note: * Indicates anticipated MACRA-eligible models (Advanced Alternative Payment Models).
Appendix- Strategies & Models
To be Worked Through
Geographic Population Model

Concept:


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Global budget(s) + non-hospital costs  Medicare total costs
for a geography
 Focuses on services provided in a particular geography
Creates responsibility for a patient population in an actionable
geographic area
 Includes services provided in local geographic area (excludes
tertiary and quaternary care provided in other hospitals)
 Allows for local focus and increases opportunities for
population health partnerships
 Creates a larger pool that mitigates high-cost patients, allowing
providers to learn how to effectively share responsibility
gradually
Geographic Population Model (cont.)

Rationale:

While the global budget already distributes responsibility for ~ 56% of
Medicare costs, CMS expects Maryland to take on increasing
accountability for TCOC over time


More partnerships with community providers are needed to continue
reducing avoidable utilization and improving outcomes for the
sustainability of the All-Payer Model


A geographic model can create an approach to engage non-hospital providers,
organize resources, and create accountability approaches across providers
MACRA is creating significant financial consequences for providers to
support value-based payments, rather than volume-based payments

21
A geographic model can cover the additional 15%-20% of Medicare spend for
non-hospital services related to hospitalizations (e.g. post acute, physician costs,
etc.)
A geographic model can help physicians and others qualify for greater funding
under MACRA if they work with hospitals that take some responsibility for
TCOC and thus become Advanced APM entities
Geographic Population Model (cont.)

Geographic Population Model: Promote All-Payer Model progression
through a payment model that creates local responsibility for patient health
outcomes and total cost of care in an actionable geographic area, first
focusing on Medicare

Model Considerations:



Base the model on geography/episodes or a combination of approaches
Consider regional organizations to service local health care community
Consider value-based payment in CY 2017/FY 2018 based on TCOC for
Medicare to use with global budgets/engage physicians through Amendment

Physician idea—value based payment could be applied to physician payment

22
Assists with MACRA eligibility

Accelerate TCOC focus for Medicare while limiting risk

For 2019, could become a shared savings model or increase value based portion of
payment tied to Medicare TCOC and outcomes

Works along with ACOs and PCMH models
Primary Care

Rationale:
 The population is aging and chronic diseases are becoming more
prevalent (e.g. 18% of MD population >65 by 2025)


Need for more care coordination and chronic care management
Taking on Medicare Total Cost of Care (for the sustainability of
the All-Payer Model) relies heavily on primary and complex and
chronic care

CMS is focused on enhancing chronic care and primary care, and is
providing significant funding sources. E.g. Chronic Care Management fees
(CCM), Comprehensive Primary Care Plus model (CPC+)

23
Main idea--Focus on the opportunity to replace the CCM fee with a
CPC+ type of model that pays care management dollars on a riskadjusted per person basis rather than a fee schedule, and support
primary care transformation
Primary Care (cont.)

Primary Care Strategy: Create a person-centered locus of
care with supporting interdisciplinary care teams across all
care settings, data-driven care coordination, and financial
incentives that move towards greater accountability

Concept:





24
Tailor care according to persons’ needs
Engage consumers and families
Help people with chronic disease and complex needs live healthier
lives, reducing downstream utilization
Continue to build care coordination infrastructure and resources
Improve care and reduce potentially avoidable utilization